Request for Win/Loss Documentation
for Personal Income Tax Filing
Slot Play Only.

Please note: A win/loss statement is documented based on recorded and rated play while utilizing your
Club Horizon Players Club Card only and may not be indicative of a person's complete and true win/loss in
regards to gaming. Information contained within this report is recorded slot play and does not indicate any rated table
games play regardless of personal ratings.

Please complete the following information. All fields are mandatory. Failure to complete this form accurately and legibly
may delay our response to completing your request.

 

Name: (as presented on Club Horizon Players Card)

Club Horizon Players Card Number:

Street Address City
State Zip Code

Please mail me my win/loss report
I will pick-up my win/loss report

I hereby request that Prairie's Edge Casino Resort owned & operated by the Upper Sioux Community furnish me with the above requested recorded information for my personal use. I hereby hold Prairie's Edge Casino Resort and the Upper Sioux Community harmless of any errors that may be contained within the requested document. I also understand that the figures contained within the requested document may not be indicative of my complete gaming win and or loss and is only that of which was recorded while utilizing my personal Club Horizon Players Card.

All requests will be processed as received. Please allow 7 days for receipt.

Primary Account Signature:
Please Type Name Here

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